A Voter's Guide to Healthcare Reform

Some presidential candidates include much more detail than others

With all the candidates running in this year's presidential election, it can be hard to sort out positions on specific issues, such as healthcare reform. With that in mind, MedPage Today brings you a "voter's guide" to the candidates' positions on reform -- just in time for Tuesday's New Hampshire primary.

Candidates are listed first by party and then in alphabetical order.

Republican

Jeb Bush: Like every other Republican candidate in the race, former Florida governor Bush would like to see the Affordable Care Act (ACA) repealed. Bush would replace the ACA with tax credits for health savings accounts (HSAs), increases in the limits for and uses of HSAs, and measures to enable small businesses to make tax-free contributions to their workers' individual, portable health plans, according to Bush's website. He also would "streamline" federal funding to states and make states responsible for enabling residents to have access to affordable catastrophic care and guaranteeing continuing coverage for individuals with preexisting conditions.

Ben Carson, MD: Carson, a retired pediatric neurosurgeon, would also repeal the ACA and give people HSAs -- which he refers to as "health empowerment accounts," or HEAs -- starting at birth; these would be paired with high-deductible health insurance plans to provide coverage for major healthcare expenses. Carson also would give Medicare beneficiaries a fixed dollar amount and let them choose from a variety of private health insurance plans, and give Medicaid beneficiaries "a private major medical insurance option for all enrollees, funded by Medicaid, through the states."

Chris Christie: Christie, the governor of New Jersey, does not discuss on his website his views on the ACA or what he might replace it with. The website does, however, address Medicare briefly. "Medicare spending growth is placing an inescapable burden on future generations ... In order to make these programs fiscally solvent for future generations and improve the kind of healthcare services and treatment those utilizing these programs receive, Governor Christie proposes keeping it simple -- if you can afford to pay more for your health benefits you will and if you can't, you won't."

"Governor Christie proposes expanding the existing sliding scale for Medicare premiums for higher-income seniors," the website continues, noting that he also supports using block grants for the Medicaid program, in which the federal government gives money to the states for spending on Medicaid recipients with very few strings attached.

Ted Cruz: Like Christie, Cruz, a Texas senator, does not have any sections devoted to healthcare reform on his website, although he does say he would "repeal Obamacare -- every single word of it."

Carly Fiorina: Fiorina, the former CEO of Hewlett-Packard, also does not have a specific healthcare section on her website, but she does include a video answer to the question: "What is your alternative to Obamacare?" The video is a clip from a Republican presidential candidate debate hosted by the Fox Business network. In it, Fiorina responds to a question about an ACA alternative with: "The alternative is to allow states to manage high-risk pools for those who really need help ... Let us try the one thing in healthcare we've never tried: the free market. Let us ensure that as patients and customers, we have the information to shop wisely for our healthcare."

Jim Gilmore: The former Virginia governor says on his website that he will repeal and replace the ACA with a "patient-oriented healthcare system." Gilmore favors many of the ideas contained in H.R. 2300, the "Empowering Patients First Act," sponsored by Rep. Tom Price, MD (R-Ga.). Those ideas include interstate sale of insurance; promotion of association health plans and HSAs; income-adjusted, "advanceable," and refundable health insurance premium credits; and malpractice and provider antitrust reform.

John Kasich: Kasich, the governor of Ohio, says on his website that he wants to use his state as a model for the country. He notes that Ohio is working through its Medicaid program to "encourage patient-centered primary care practices that go the extra distance to keep people healthy and thereby help control costs." Ohio Medicaid also is working with private insurers in the state to share any cost savings from those practices with the providers. Kasich also wants to use episode-based, or bundled, payments to help lower costs.

"The Ohio model provides a path forward for the nation: patient-centered care, choices, market competition, decentralized decision-making, higher quality, respect for individuals and an end to Obamacare's big government interference," the website says.

Marco Rubio: Rubio, a Florida senator, outlined his healthcare plan in an article posted on the Politico website. Rubio says he will "work with Congress to create an advanceable, refundable tax credit that all Americans can use to purchase health insurance," with the value of the credits increasing each year. In addition, he plans to cover patients with preexisting conditions through state-based high-risk pools and also will encourage use of HSAs. Like Christie, he supports block-granting Medicaid and, like Carson, he supports a "premium support" system for future Medicare beneficiaries.

Donald Trump: No information about healthcare can be found on the website of Trump, a real estate mogul based in New York City. But he has been quoted as saying he would "end Obamacare and replace it with something terrific, for far less money for the country and for the people."

Democratic

Hillary Clinton: The former Secretary of State says on her website that she wants to keep the ACA and build on it. Clinton says she will lower co-pays and deductibles, reduce prescription drug costs, reward value and quality in healthcare, and expand reimbursement for telehealth. In addition, "Hillary is continuing a lifelong fight to ensure women have access to reproductive healthcare ... As president, she will continue defending Planned Parenthood, which provides critical health services including breast exams and cancer screenings to 2.7 million women a year."

Bernie Sanders: The senator from Vermont, an Independent, supports a "Medicare for all" single-payer healthcare system. Sanders' plan, which he says will cost about $1.38 trillion annually, would "cover the entire continuum of health care, from inpatient to outpatient care; preventive to emergency care; primary care to specialty care, including long-term and palliative care; vision, hearing and oral health care; mental health and substance abuse services; as well as prescription medications, medical equipment, supplies, diagnostics and treatments," according to the document posted on the Sanders website.

"Patients will be able to choose a health care provider without worrying about whether that provider is in-network and will be able to get the care they need without having to read any fine print or trying to figure out how they can afford the out-of-pocket costs," it continues. The plan would be paid for largely through increased taxes and a premium paid by employers; however, Sanders says the average family would save more than $5,000 each year since they wouldn't have to pay premiums or deductibles.

Green

Jill Stein, MD: Like Sanders, Green Party presidential candidate Jill Stein, MD, favors "Medicare for all" single-payer system. "The expensive health insurance required under the ACA does not cover all of a patient's health care and high medical bills will still force many families into bankruptcy," said a press release on Stein's website. "Tens of millions of Americans will be left without insurance and far more will be forced to pay for inadequate coverage."

Stein, who opposes putting Medicare beneficiaries into private health insurance plans, "would expand the services covered under Medicare and enable it to negotiate lower prices with drug companies," the release continued. "In recent years it has been burdened with excessive and unnecessary red tape."

Libertarian

Gary Johnson: Former New Mexico governor Gary Johnson is running for president as a Libertarian candidate. Although his website does not have a healthcare reform section, it does say this about healthcare in its "Personal Freedom" section: "Imagine [the Founding Fathers'] shock to learn that the government has decided it is appropriate to tell adults what they can put in their bodies -- and even put them in jail for using marijuana, while allowing those same adults to consume alcohol and encouraging the medical profession to pump out addictive, deadly painkillers at will."

Johnson was also quoted in 2012 by the website Politic365 as saying that Obamacare was the "torpedo" that would cause the country's "sinking ship" of an economy to collapse. In the same article, Johnson said Medicare spending should be slashed and that when free markets for healthcare are genuinely operating in the U.S., the number of physicians could double.

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